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HSC-6 Command Investigation
HSC-6 Command Investigation
COMMANDER
UNITED STATES PACIFIC FLEET
250 MAKALAPA DRIVE
PEARL HARBOR, HAWAII 96860-3131
5830
Ser N00/074
17 Apr 14
FINAL ENDORSEMENT on CDR
(bX3), (b)(6)
b ..3...b..6) ltrs of 23 Nov 13
and CDR
(b)(3), (b){6)
From:
To:
Subj:
Ref:
(k)
COMNAVAIRSYSCOM
Encl:
142000Z
Feb
14
Executive Summary
Subj:
IO Opinion 16.
32
Subj:
stable heading were not taken. While the surface and aviation
communities should have done more to train the CO on similar mishaps,
she was ultimately r e sponsible for the safe operation of her ship.
3.
Administrative Changes
d. Delete page number 145 and replace with page number 26 at the
center bottom of the FIFTH ENDORSEMENT on CDR
(b)(3), (b)(6)
and
CDR
(b)(3), (b)(6)
l tr of 2 3 Nov 13 .
CDR
e.
f.
on CDR
Findings of Fact.
33
Subj:
5. Opinions.
I concur with all opinions as modified through the
SIXTH ENDORSEMENT, except as modified below.
a. Opinion 7: Modify Opinion 7 to read:
"Though BUNO 167895
"INDIAN 617" was properly authorized and scheduled for the assigned
mission on 22 September 2013, subsequent changes to the CSG's schedule
did not trigger changes to the helicopter logistics schedule. WPL's
Commanding Officer accepted a higher risk helicopter evolution at
flank speed with quartering seas in an effort to execute a schedule
that was pressurized on one side by delays to the helicopter logistics
schedule, and on the other side by the need to have WPL proceed to
relieve the uss STOCKDALE (DDG 106) as plane guard in support of the
STOCKDALE's replenishment-at-sea schedule. By attempting to
accomplish both tasks simultaneously, without appropriately managing
risk, the ship's Commanding Officer traded away safety margin during
the execution of these two competing events. [Findings of Fact 7-11]"
b. Opinion 10: Modify Opinion 10 to read:
"Though the OOD did
not violate any published procedures during WPL's course change, the
Commanding Officer and OOD failed to heed the caution contained on
page 7-4 of reference (c), which advises that "special care should be
exercised when maneuvering while helicopters are turning on deck." As
a result, they failed to identify and properly assess the increasing
danger to the vessel, aircraft, and crew associated with maneuvering
at flank speed on a heading that placed swells on the starboard
quarter while a helicopter, though chocked and chained, operated on
the flight deck. [Findings of Fact 32-36, 38, 68 and 69]"
d. Opinion 11: Modify Opinion 11 to read:
"The Commanding
Officer accepted increased risk to life and property by maneuvering at
flank speed and permitting the OOD to execute a course change that
placed the seas on WPL's starboard quarter while INDIAN 617 operated
on deck when the operational urgency to do so could have been negated
had she communicated her situation to the Helicopter Element
Coordinator (HEC). [Findings of Fact 38, 40 and 41)"
e. Opinion 12: Modify Opinion 12 to read:
"The combined effects
of wave height, starboard quartering seas, and ship's speed set the
34
[Findings of Fact
26-29,
(1) CNSP and CNAP shall conduct a safety stand-down for all
helicopter commands and all frigates and destroyers to address the
dangers of seawater intrusion during helicopter operations.
Commanders shall ensure that reference (k} , which is Change 11 to
reference (c), and this and similar mishaps are briefed. The safety
stand-downs for Pacific Fleet units shall be completed by 30 May 2014.
CNAP and CNSP shall also coordinate with Commander, Naval Air Force,
Atlantic (CNAL) and Commander, Naval Surface Force, Atlantic (CNSL).
35
Subj :
Reference (k) .
Reference (c) at page 7-4 (version in effect 22 Sep 2013).
36
Subj:
Accountability
Conclusion
37
WPL rolled moderately during the course change from 130 to 190,
but at course 190, rolls became excessive with increasing magnitude.
o
At 1242, WPL rolled 12 to starboard.
o
At 1243, WPL changed course from 190 to 195, and rolls got worse.
o
At 1244, WPL rolled 16.6 to starboard and a thick "wall" of water
enveloped INDIAN 617, which was still turning on deck.
o
At 1245, a crash on deck was reported.
o
At 1247, there was a report of INDIAN 617 going overboard.
e. When viewed in isolation, at every moment, CDR Vavasseur's
maneuvering was within the envelope:
o
DDG110INST 3750.1A (written before NAVAIR promulgated Change 11 to
reference (c)) places no restrictions for maneuvering the ship while
at red deck with chocks and chains installedi
o
At the time of the incident, reference (c) only restricted
maneuvering in high sea states, which was not technically the
situation at the time of the mishapi and,
o
At the time of the incident reference (c) also stated that, "once
chocks and chains are installed, ship is free to maneuver."
...
Subj: :
39
Subj: :
Copy to:
COMNAVAIRPAC
COMNAVSURFPAC
COMNAVFORCENTCOM
NAVAIR
NAVSEA
NAVSAFECEN
COMCARSTKGRU 11
COMCARAIRWING 11
CDR
(b}(3}, (b}(6}
CDR
(b}(3}, (b}(6}
40
BOX 357051
5830
Ser N01J// 17 1
25 Feb 14
From:
To:
(b)(3), (b)(6)
l tr of 17 Jun 13
and CDR
b 3 , (b)(6)
Subj:
(b)(5)
(b)(5)
(b)(5)
(b)(5)
b 5
(b)(5)
(b)(5)
b 5
(bX5l
(b)(5)
(b)(5)
(b)(5)
(b)(5)
.b..5.
28
Subj:
4.
(b)(5)
(b)(5)
.b. .5.
b.
(b)(5)
(b)(5)
(b)(5)
(b)(5)
c.
(b)(5)
(b)(5)
,b 5
(b)(5)
(b)(5)
(b)(5)
(bX5l
29
D. H. BUSS
Copy to:
COMPACFLT
COMNAVSURFPAC
COMNAVFORCENTCOM
COMCARSTRKGRU 11
COMDESRON 23
COMCARAIRWING 11
CDR
(b)(3), (b)(6 )
CDR
.b .3.. (b)(6)
30
IN REPLY REFERTO
5830
ser N00J/108
24 Jan 14
_b 3_, _b 6_
From:
To:
Copy to:
COMMANDER NAVAL FORCES CENTRAL
COMDESRON TWO THREE
COMCARAIRWING ELEVEN
COMSTRKGRU ELEVEN
COPEMAN
COMMAND
145
DEPARTMENT OF T HE NAVY
IN REP\.Y TO:
5830
Ser N013 / 195
23 Dec 13
FOURTH ENDOR SEMENT on CDR
(b)(3), (b)(6)
From:
To:
Via:
(b)(3), (b)(6)
ltr of 23 Nov 1 3
and CDR
(b)(3), (b)(6)
J. W. MI LLER
Copy to :
COMDESRON TWO THREE
COMCARAI RWING ELEVEN
COMSTRKGRU ELEVEN
COMMANDER
UNIT 25066
FPO AE 96601-4703
IN REPLY REFER TO
5830
Ser N00J/312
20 Dec 13
From:
To:
Via:
(b)(3), (b)(6)
ltr ot 15 Nov 13
and CDR
(b)(3), (b)(6)
M. S. WHITE
Copy to :
COMCARAIRWING ELEVEN
24
UNIT 25073
FPO AP 96601-4722
IN REPLY REFER TO
5800
Ser N00/250
15 Dec 13
SECOND ENDORSEMENT on CDR
(b)(3), (b)(6)
ltr of 23 Nov 13
and CDR
(b)(3), (b)(6)
From:
To:
Via:
Subj:
1.
H.
T _
WORKMAN
FPO AP 96601-4408
5830
Ser 00/359
10 Dec 13
FIRST ENOORSEMENT on CDR
(b)(3), (b)(6)
ltr of 23 Nov 13
and CDR
(b)(3), (b)(6)
From:
To:
Via:
Subj:
22
23 Nov 2013
From:
To:
Subj :
Ref :
Encl :
CDR
USN
(b)(3), {b)(6)
CDR
(bX3), {bX6)
, USN
COMNAVSURFOR Ships
Subj:
Subj:
Bil l
22 Sep 13
3141 - 3
(b)(3), (b)(6)
b __3_, b __6_
letter for LT
.b. .3...b..6.
Inspection Records
Subj :
Jonathan S . Gibson
(b)(3), (b)(6)
, HSC-6
Det 1
Standards sheets
System Data
(63) Flight Log Book en t ries for LCDR Landon L . J ones and
CWO3 Jonathan s. Gibson
(64) Flight Deck Cha i n Inventory & Maintenance Records
(65) Personal Observations of the crash site from the
Report
5 . Line of
LCDR Landon
and 68) . A
i s included
Findings of Fac t
1 . MH-60S Aircraft BUNO 167895, INDIAN 617 ( IN 617) and USS
WILLIAM P. LAWRENCE (DDG 110) (WPL) were involved in a Class A
Flight Mishap on 22 September 2013 .
[ Enclosures 29, 41, 70 and
65]
2.
LCDR Landon L. Jones , USN and CWO3 Jonathan S. Gibson, USN
were onboard BUNO 167895 when the mishap occurr ed.
All
crewmembers were active duty US Navy Personnel assigned to HSC-6
deployed with NIMITZ Carrier Strike Group and embarked on USNS
RAINIER (AOE 7} during the mishap .
[Enclosure 41]
3 . The mishap occurred on the flight deck of WPL on 22
September 2013. (Enclosures 29, 41 and 65)
4.
The mishap resulted in complete destruct i on of the Aircraft
and substantial damage to the WPL flight deck .
(Enclosures 30
and 65)
5.
[Enclosures 23)
6 . AWS1
(b)(3), (b)(6)
, USN , assigned t o HSC-6 deployed with
NIMITZ Carrier Strike Group and embarked on USNS RA I NIER (AOE 7}
was injured during the mishap .
[Enclosure 2]
7 . According to Naval Aviation Logistics Command Management
Subj :
[Enclosure 43)
Subj:
16. CWO3 Jonat han S. Gibson was HSC-6 Det 1 Training Officer.
He was a Helicopter Second Pilot (H2P).
He had 436 . 9 total
flight hours with 225.6 flight hours in H-60 model aircraft .
[Enclosures 46 and 63]
17 .
IN 617 Fli ght Crew clearances, qualifications, and
designations were current and appropriate for the assigned
mission including Naval Air Training and Operating Procedures
Standardization (NATOPS ) , Instrument , Egress Training, Naval
Aviation Survival Training , Aircrew Coordination Training and a
current Medical up-chit.
[Enclosures 45-56]
18 . LCDR Jones' and CWO3 Gibson's Aviation Life Support Systems
were in compliance with all periodic maintenance inspections.
No flight gear for LCDR Jones or CWO3 Gibson was found onboard
USNS RAINER (AOE 7) .
[Enclosure 57 and 32]
27. Observed weather for the mishap area was reported by the
NIMITZ SGOT as 30.6 degrees Celsius; sea surface temperature
30.6 degrees Celsius; sea height 2- 3 ft with a period of 2-3
seconds; swell of 2-4 ft from 330T with a period of 4- 6 seconds;
altimeter setting of 29 . 77; surface winds 320 degrees true at 28
knots; sky clear; visibility 6 nautical miles with haze; no
thunderstorms; no turbulence, icing or precipitation .
(At 1256C
USS NIMITZ was 9nm from WPL).
[Enclosures 62)
28. The WPL Surface Weather Observations log recorded seas of 3
feet or less for the entire day and swell of 4 to 5 feet
throughout the day, with swell from 250 to 320 degrees true for
a calculated combined sea height of 5.0 to 5.8 feet.
[Enclosure
34)
29. The ship OOD stated seas during that time were 5-7 feet
with a 4-5 second period.
[Enclosure 5)
Subj :
35. The OOD, JOOD and CONN ship pitch was indicated at 1 degree
and ship roll was indicated at 3 to 6 degrees.
[Enclosures 5 , 6
and 7]
36.
Ship's Inertial Navigation System data for WPL indicted
ship pitch varied from +0 . 6 to -0 . 9 degrees and ship roll
varied from +4.2 to -6.3 degrees between 1230C and 1240C .
Positive values are defined as bow up for pitch and starboard
roll .
[Enclosure 60]
37.
Prior to fl i ght operations, WPL completed an Underway
Replenishment and had been ordered to make "best speed" to take
station on USS NIMITZ (CVN 68), which was 30 nm to the south, in
order to relieve USS STOCKDALE (DDG 106) (STK) so that STK could
conduct Underway Replenishment .
[Enclosures 4 and 5]
38 . The following sequence of events occurred during IN 617
flight operations with WPL :
1130C:
IN 617 checks in with WPL [Enclosure 66]
10
39. The co and OOD stated that increasing speed to 160 rpm (3031 knots) on course 130 resulted in winds stable and in the
envelope for Green Deck.
[Enclosures 4 and 5]
40. The CO entered the bridge at 1228C . The CO personally
monitored the winds during IN 617's second approach and
11
12
Subj:
55. The flight deck phone talker saw a wave from astern hit the
aft rotors immediately before the large wave.
[Enclosure 25]
56 . Multiple witnesses observed the IN 617 fuselage began to
shake violently.
[Enclosures 3, 6, 11, 12, 14, 15, 19 and 27]
57 . Multiple witnesses observed the rotor blades impact the
flight deck.
[Enclosures 3, 5, 11, 12, 21 and 27]
58. Multiple witnesses observed IN 617 rotate clockwise and
move starboard and forward on the flight deck after water
impact .
[Enclosures 3, 4, 11, 12, 15, 17 - 19 and 25]
59. Multiple flight deck witnesses ran into the starboard
hangar as IN 617 moved towards the starboard side of the ship.
60. Several witnesses who sought shelter in the starboard
hangar heard what sounded like rotors hitting the hangar door
but did not hear engine noise.
13
Subj :
63 . After the l arge rol l, IN 617 then moved across the flight
deck and went overboard to port.
[Enclosures 2, 8 , 15, 17, 21
and 27]
64 . Multiple witnesses saw both pilots in the aircraft as it
moved about the flight deck .
[Enclosures 2, 3 , 13 , 22 and 27]
65 .
IN 617 went overboard from WPL at N22 34 ' 18" E037 25 '
29". WPL was heading approximately 195 true at time of impact.
Wreckage was distr i buted to the south of the impact down the
line of set and drift at 160 true at 1.63 knots to a maximum of
N22 29 . 47 ' E037 22 . 49 ' .
[Enclosures 29 , 60 and 62 ]
66 .
Post-mishap photographs show indications of rotor impact
with the f l ight deck as well as signs of damage 20 feet above
the flight deck. The aircraft tail rotor was found on the aft
starboard side of the flight deck. The empennage sect i on of the
a i rcraft was found on the forward port s i de of the flight deck .
The empennage showed signs of breaking off the aircraft cabin by
twisting to the right . The right main landing gear broke off
the aircraft at the p i vot point. Both pilot doors were found on
the f l ight deck wi th door handles in the locked position and
both emergency release handl es shear wired in the closed
pos i tion .
[Enclosure 65]
67 . Reference (c) , on page 9-1, states : " Comb i ned wave and
swell effect can result in seawater over the flight deck of FFG
7, DDG 5 1, and DDG 79 class sh i ps, resulting in helicopter
damage. Addit i ona l ly, the wave action created by the Venturi
effect between UNREP sh i ps can cause rotor system damage. "
68 . Reference (c) , on page 7-4 , states : "Specia l care should be
exercised when maneuvering while helicopters are spinning on
deck . In high sea states , only maneuvering to maintain a safe
navigation course is recommended. "
69 . Reference (c) , Figure 2- 13 , states : " Once chocks and chains
are installed, ship is free to maneuver".
70 . The chains used to secure IN 617 to the deck were unable to
be ident i f i ed as f l ight deck crew do not reco r d wh i ch chains are
14
Subj :
75 . According to the HSM-75 Combat Element (CEL) 4 Officer-inCharge, there was a strong safety culture onboard WPL. HSM-75
CEL 4 flew the morning of the incident and attempted to fly the
previous night in similar conditions. The previous night's
flight was not cancelled for sea state or ship motion. The
conditions on 22 Sep 2013 were the roughest seas WPL had
conducted flight operations in since Jan 2013 during transit
across the Pacific Ocean.
During that transi t in Jan 2013, WPL
operated helicopters with rolls up to 12 .
[Enclosures 28]
15
Subj:
s.
OPINIONS
2.
IN 617's flight crew was fully qualified, per all known and
current instructions, to perform the duties they were assigned
on the HSC- 6 flight schedule on 22 Sep 2013 .
[Find i ngs of Fact
11, 14-17 )
3.
WPL's crew was fully qualified, per all known and current
ins truct io ns , to perform the duties they were assigned on 22 Sep
2013.
[Fi ndings of Fact 20, 21 and 24)
4.
The LSE and Port Chock and Chainman were not ass i gned to
their positions on the cur rent WPL watchbill, but this was not a
contributing factor to the mishap.
[Findings of Fact 23, 42 and
43]
5. The mishap aircrew was in compliance with all crew rest and
currency requirements. While some stress factors were
identified for the aircrew, human error is not suspected as a
16
Subj :
(b)(5)
(b)(5)
(b)(5)
8 . While IN 617 was chocked and chained on the deck of WPL , the
ship took a large roll to port followed by a l arger correct i ng
roll to starboard.
This resu l ted i n a wave of unknown size
impacting the starboard aft port i on of WPL's hull, which in turn
resulted in a large amount of wa t er impacting the rotor blades/
pushing them down and possibly impacting the fuselage.
This
caused the tail to break off and the helicopter to shake
The violent shaking , in turn , resulted in the
violently.
helicopter breaking free of the chocks and cha ins , and also
caused the left and right pilot doors to detach from the
fuselage.
The helicopter then moved forward and starboard while
the rotor blades and other parts of the helicopter i mpacted
surrounding structures.
WPL took another strong roll to port,
which resulted in the helicopter continuing the clockwise
rotation while the rotor b l ades carne apart and the empennage
section rotated into the forward port corner of the flight deck.
At this time, the empennage section broke off the fuselage and
rema i ned on WPL while the fuselage slid overboard off the port
side of the flight deck . Enclosure 61 provides a graphical
recreation of the JAGMAN Investigating Officers' opinion on the
[Findings of Fact 1- 4, 25 1 53, 55sequence of mishap events .
58, and 61-66]
9 . LCDR Jones and CWO3 Gibson 1 the only aircrew onboard IN 617
at the time of the mishap, were both likely incapacitated by the
violent aircraft motion and unable to execute emergency egress .
Based on witness accounts of sounds they heard 1 it is possible
17
Subj:
(b)(5)
(b)(5)
b 5
(b )(5)
(b)(5)
(b)(5)
(b)(5)
11.
(b)(5)
(b)(5)
(b)(5)
(b)(5)
b 5
(b)(5)
(b)(5)
(b)(5)
(b)(5)
(b )(5)
12 .
(b)(5)
(b)(5)
(b)(5)
b . 5.
(b)(5)
18
Subj :
16 .
(b )(5)
(b)(5)
(b)(5)
,b.,5.
(b)(5)
(b)(5)
(b)(5)
.b .5.
,b.,5.
(b)(5)
(b)(5)
(b)(5)
(b)(5)
.b .5.
(b)(5)
.b . 5.
b 5
(b)(5)
(b)(5)
(b)(5)
(b)(5)
(b)(5)
20
the flight deck camera must include recording capability and the
requirement to record all flight ope rations . This wou l d
si gnificantly improve safety and mishap prevention.
2 . The JAGMAN Investigating Officers believe this incident was
caused by water corning up the side of t he flight deck and
impacting the turning rotor blades of t he hel icopter.
Investigation should be conducted into material modifications to
DDG class ships or changes to standard operating procedures in
order to mitigate risks of water impacting helicopters on deck .
Potential solutions could include modification of flight deck
nets to p rov ide a solid barrier to deflect water, disengaging
(b)(6)
(b)(6)
(bX3), (bX6)
(b)(3), (b)(6)-
21